Treatment of Anterior Saphenous Vein Incompetence: A Systemic Review of the Literature and Payer Coverage Policies

Introduction, Objectives, and/or Purpose: The Anterior Saphenous Vein (ASV) is a common source of superficial venous reflux present in approximately 10% of patients with primary disease and up to 30% of patients with recurrent disease. In the past there has been a debate if the ASV is simply a branch of the GSV or its own axial vein with a distinct natural history that requires different treatment considerations than a branch varicosity. It is now better understood anatomically that the ASV is clearly an axial vein with its own proper fascial compartment that is distinct from the GSV. There is an increasing appreciation that addressing ASV reflux is important not only in achieving optimal outcomes in the short term but also in reducing the risk of recurrence after treatment in the long-term. Inconsistent and non-evidenced based insurance coverage policies can be an impediment to treatment access for patients. This systematic review was designed to examine curretnly published evidence regarding ASV treatment and survey insurance coverage impediments to treatment in the United States.

Methods: PubMed and Google Scholar databases were searched for published peer reviewed clinical studies. Relevant articles were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they contained relevant terms for Anterior Saphenous Vein, such anterior, accessory, lateral, saphenous, or any combination. Articles were excluded if they did not relate to lower extremity chronic venous disease. We also conducted a cross-sectional analysis of publicly accessible insurance policies in the United States. Of those policies that extended coverage, medical necessity criteria were abstracted. The medical coverage policies for the treatment of varicose veins were evaluated using the American Venous Forum’s Venous Policy Navigator. This contains up-to-date pre-authorization terminology and documentation requirements from more than 226 payers in a web-based search format. This resource is updated monthly.

Results: Of the 1,910 articles published in English screened, 24 duplicates were removed and 1,886 were selected for full review following the PRISMA inclusion criteria. A total of 1,703 publications were found to be irrelevant and 183 full text studies were assessed for edibility. An additional 25 were excluded as being irrelevant to the topic leading to 158 that were included in the review. (Figure 1) Additionally, there were 226 pertinent insurance coverage policies that were included in the insurance policy review (Table 1). The unique anatomic and clinical treatment considerations for ASV treatment are discussed for both patients presenting with primary ASV reflux, as well as ASV reflux after prior superficial vein treatment. The main out come is that the published literature reveals that patients with ASV reflux tend to present with more advanced symptoms, a higher percentage of CEAP class C4 and above, higher rVCSS scores and develop superficial phlebitis at a higher rate than patients with great saphenous vein (GSV) reflux. Treatment with endovenous ablation has outcomes that are similar to treatment of the GSV.

Insurance polices were inconsistent in their coverage of ASV treatment. In 155 of 226 (68.6%) policies reviewed, coverage of ASV ablation was allowed while 62/226 (27.4%) did not specify coverage and 9/226 (4.0%) specified ASV treatment was not covered. Of the 155 that provide ASV coverage, 98 (63.2%) only allow coverage dependent on criteria such as prior treatment of the great saphenous vein.

Conclusion(s): ASV reflux is a common source of chronic venous disease and its treatment is important to adequately reduce symptoms and risk of recurrence. There are unique considerations in the treatment of patients with ASV reflux stemming from the distinct anatomy, clinical presentation, treatment considerations and outcomes. Additionally, there are barriers to access to care resulting from inconsistent and sometimes arbitrary insurance coverage provisions. Findings from a systemic review of the literature support the consensus that ASV reflux is far from being a less important afterthought following GSV treatment and may in fact have a worse natural history if left untreated. Given there is ample evidence to support ASV treatment when medially indicated and there is an absence of evidence to either restrict its use or not cover its treatment, all payers should consider updating their policies to be consistent with current published evidence and consensus. Specifically, payers should allow coverage for treatment for patients with symptomatic ASV reflux without any restrictive criteria other than that the reflux be severe and the medical necessity criteria be present. Venous societies and vein experts should continue to advocate for payers to update varicose vein treatment policies to reflect the substantial published clinical evidence and expert consensus so that patients with ASV reflux can be appropriately treated.